Percutaneous Closure of Paravalvular Regurgitation After Third-Generation Transcatheter Aortic Valve Replacement

Significant paravalvular leak regurgitation (PVLR) after transcatheter aortic valve replacement (TAVR) is a well-known complication associated with disabling symptoms related to heart failure and hemolysis or both, with poor prognostic implications. Although challenging and technically demanding, percutaneous closure is an effective treatment option for high-risk patients with symptomatic PVLR. Here, we present two cases of transcatheter PVLR closure after replacement of third-generation (one self-expandable and one balloon-expandable) transcatheter aortic valves, each with peculiar challenges, and the strategies adopted to increase the success rate of percutaneous closure.

Association of individual aortic leaflet calcification on paravalvular regurgitation and conduction abnormalities with self-expanding trans-catheter aortic valve insertion

Background

Complication rates of paravalvular aortic regurgitation (PVR) and permanent pacemaker insertion remain high in patients undergoing trans-catheter aortic valve insertion for severe aortic stenosis. The spatial distribution of calcium between individual aortic valve leaflets, and its potential role in these complications is gaining interest. We aimed to assess the accuracy of individual aortic valve leaflet calcium quantification, and to determine its effect on the frequency of these complications.

Methods

This was a retrospective study of 251 patients who underwent trans-catheter aortic valve insertion using the Evolut RTM valve. The off-line Terarecon software platform was used for Agatston scoring the short axis views.

Results

There was a correlation between the sum of the individual leaflet and the total aortic valve calcium score. There was a univariate association between an increase [per 100 Agatston unit (AU)] in both right coronary leaflet (RCL) and left coronary leaflet (LCL) calcium with the risk of PVR. There was an association between an increase in LCL calcium score (per 100 AU) and need for post-implantation balloon aortic valvuloplasty (BAV). There was no association between individual leaflet calcification on the risk of permanent pacemaker insertion.

Conclusions

This study supports the idea that a quantifiable and reproducible method of individual valve leaflet calcification score may serve as an independent risk factor for paravalvular regurgitation, beyond visual assessment of asymmetry. However, the same may not be true of spatial calcium distribution and permanent pacemaker implantation (PPI).

Impact of Balloon Postdilation on Six-Year Mortality After Transcatheter Aortic Valve Replacement

OBJECTIVES

Balloon postdilation (BPD) is one strategy for decreasing paravalvular leakage, but its effect on long-term mortality remains unclear. The authors sought to clarify whether BPD influences long-term mortality of patients with transcatheter aortic valve replacement (TAVR).

DESIGN

Single-center retrospective study.

SETTING

National heart center; single institution.

PARTICIPANTS

Participants were patients who underwent TAVR in the authors' hospital from January 2014 to December 2016. A balloon-expandable Sapien XT or Sapien3, or self-expandable CoreValve or Evolute R, was implanted according to the decision of the surgeon considering degree of calcification of the aortic valve.

INTERVENTIONS

No interventions.

MEASUREMENTS AND MAIN RESULTS

Multivariate Cox regression analysis and inverse probability weighted estimation were performed using a propensity score to examine whether BPD influenced six-year mortality. Ultimately, 180 patients were analyzed. During the follow-up period, with a median of 1104 (interquartile range: 730-1463) days, 41 patients died and cumulative incidence of mortality at six years was 22.8%. Society of Thoracic Surgeons score (odds ratio [OR]: 2.257, 95% CI: 1.213-4.197, p = 0.010)], BPD (OR: 0.306, 95% CI: 0.098-0.953, p = 0.041), and paravalvular regurgitation of at least moderate-to-mild severity after deploying (OR: 5.407, 95% CI: 1.626-17.978, p = 0.006) were significant factors of mortality.

CONCLUSIONS

BPD is associated with reduced six-year mortality.

Transcatheter Aortic Valve Replacement: The Experience of One Brazilian Health Care Center

Objective

Transcatheter aortic valve replacement has been an alternative to invasive treatment for symptomatic severe aortic stenosis in high risk patients. The primary endpoint was 30-day and 1-year mortality from any cause. Secondary endpoints were to compare the clinical and echocardiographic variation pre-and post- transcatheter aortic valve replacement, and the occurrence of complications throughout a 4-year follow-up period.

Methods

This prospective cohort, nestled to a multicenter study (Registro Brasileiro de Implante de Bioprótese por Cateter), describes the experience of a public tertiary center in transcatheter aortic valve replacement. All patients who underwent this procedure between October 2011 and February 2016 were included.

Results

Fifty-eight patients underwent transcatheter aortic valve replacement. The 30-day all-cause mortality was 5.2% (n=3) and after 1 year was 17.2% (n=10). A significant improvement in New York Heart Association functional classification was observed when comparing pre-and post- transcatheter aortic valve replacement (III or IV 84.4% versus 5.8%; P<0.001). A decline in peak was observed (P<0.001) and mean (P<0.001) systolic transaortic gradient. The results of peak and mean post-implant transaortic gradient were sustained after one year (P=0.29 and P=0.36, respectively). Left ventricular ejection fraction did not change significantly during follow-up (P=0.41). The most frequent complications were bleeding (28.9%), the need for permanent pacemaker (27.6%) and acute renal injury (20.6%).

Conclusion

Mortality and complications in this study were consistent with worldwide experience. Transcatheter aortic valve replacement had positive clinical and hemodynamic results, when comparing pre-and post-procedure, and the hemodynamic profile of the prosthesis was sustained throughout follow-up.

Clinical utility of a predictive model for paravalvular aortic regurgitation after transcatheter aortic valve implantation with a self-expandable prosthesis

Background

Methods

Results

Conclusion

Percutaneous Closure of Paravalvular Leaks: A Systematic Review

Paravalvular leak (PVL) is an uncommon yet serious complication associated with the implantation of mechanical or bioprosthetic surgical valves and more recently recognized with transcatheter aortic valves implantation (TAVI). A significant number of patients will present with symptoms of congestive heart failure or haemolytic anaemia due to PVL and need further surgical or percutaneous treatment. Until recently, surgery has been the only available therapy for the treatment of clinically significant PVLs despite the significant morbidity and mortality associated with re-operation. Percutaneous treatment of PVLs has emerged as a safe and less invasive alternative, with low complication rates and high technical and clinical success rates. However, it is a complex procedure, which needs to be performed by an experienced team of interventional cardiologists and echocardiographers. This review discusses the current understanding of PVLs, including the utility of imaging techniques in PVL diagnosis and treatment, and the principles, outcomes and complications of transcatheter therapy of PVLs.

Comparative meta-analysis of balloon-expandable and self-expandable valves for transcatheter aortic valve replacement

BACKGROUND

Balloon-expandable valves (BEVs) and self-expandable valves (SEVs) are two major types of valves utilized for transcatheter aortic valve replacement (TAVR). We conducted a meta-analysis of available studies to compare the safety and efficacy of these two valve types.

METHODS

Medline search was conducted using standard search terms to determine eligible studies. Primary outcomes of the meta-analysis included death and stroke at 30days and 1year. Pooled estimates of procedural outcomes were also compared between the valve types. Analysis was performed for entire cohort and separately for patients undergoing transfemoral TAVR (TF-TAVR).

RESULTS

Analysis of entire cohort revealed similar 30-day mortality in the SEV and BEV cohorts. There was no significant difference in the incidence of stroke at 30days between the two study groups. Both pooled comparisons demonstrated a significant heterogeneity with I(2)>50%, necessitating the use of random effect modeling. We observed a significantly higher incidence of new pacemaker implantation, aortic regurgitation≥2+ at 30days, valve embolization, and need for >1 valve following SEV implantation compared with BEV implantation. Analysis of TF-TAVR cohort showed higher 30day [IRR (95% CI): 1.34 (1.19-1.52)] but a similar 1-year mortality [IRR (95% CI): 1.07 (0.96-1.19)] for SEV compared to BEV implantation.

CONCLUSION

Compared to BEV implantation, SEV implantation was associated with a similar risk of mortality and stroke at 30-day and 1-year follow-up duration. Analysis of the TF-TAVR cohort revealed a significantly higher mortality at 30days among patients undergoing SEV implantation, compared with BEV implantation. In addition, there was a significantly higher incidence of other adverse events noted above, following SEV implantation, compared with BEV implantation.

The impact of transcatheter aortic valve implantation on left ventricular performance and wall thickness - single-centre experience

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is a treatment alternative for the elderly population with severe symptomatic aortic stenosis (AS) at high risk for surgical aortic valve replacement (SAVR).

AIM

To assess the impact of TAVI on echocardiographic parameters of left ventricular (LV) performance and wall thickness in patients subjected to the procedure in a single-centre between 2009 and 2013.

MATERIAL AND METHODS

The initial group consisted of 170 consecutive patients with severe AS unsuitable for SAVR. Logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 21.73 ±12.42% and mean age was 79.9 ±7.5 years.

RESULTS

The TAVI was performed in 167 (98.2%) patients. Mean aortic gradient decreased significantly more rapidly after the procedure (from 58.6 ±16.7 mm Hg to 11.9 ±4.9 mm Hg, p < 0.001). The LV ejection fraction (LVEF) significantly increased in both short-term and long-term follow-up (57 ±14% vs. 59 ±13%, p < 0.001 and 56 ±14% vs. 60 ±12%, p < 0.001, respectively). Significant regression of interventricular septum diameter at end-diastole (IVSDD) and end-diastolic posterior wall thickness (EDPWth) was noted in early (15.0 ±2.4 mm vs. 14.5 ±2.3 mm, p < 0.001 and 12.7 ±2.1 mm vs. 12.4 ±1.9 mm, p < 0.028, respectively) and late post-TAVI period (15.1 ±2.5 mm to 14.3 ±2.5 mm, p < 0.001 and 12.8 ±2.0 mm to 12.4 ±1.9 mm, p < 0.007, respectively). Significant paravalvular leak (PL) was noted in 21 (13.1%) patients immediately after TAVI and in 13 (9.6%) patients in follow-up (p < 0.001). Moderate or severe mitral regurgitation (msMR) was seen in 24 (14.9%) patients from the initial group and in 19 (11.8%) patients after TAVI (p < 0.001).

CONCLUSIONS

The TAVI had an immediate beneficial effect on LVEF, LV walls thickness, and the incidence of msMR. The results of the procedure are comparable with those described in other centres.

Impact and natural history of postprocedural aortic regurgitation on early and midterm mortality following transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis

BACKGROUND

Post-procedural aortic regurgitation (AR) negatively impacts the prognosis after trans-catheter aortic valve implantation. However, data evaluating the impact of different post-procedural AR grades (particularly mild) on clinical outcomes are still important.

AIM AND METHODS

A retrospective cohort analysis was performed on all consecutive patients with severe aortic stenosis who underwent trans-catheter aortic valve implantation between July 2008 and August 2011 in a single Institution. Aim of the study was to evaluate the impact of different post-procedural AR grades on early and mid-term clinical outcomes.

RESULTS

322 consecutive patients were evaluated. At post-procedural echocardiographic evaluation: 105 (32.6%) patients had no AR, 204 (63.4%) mild AR and 13 (4%) moderate/severe AR. In-hospital mortality was higher in patients with moderate/severe AR than in those with absent or mild AR (38.5% vs. 2.6%, P < 0.001). At a median clinical follow-up of 342 days [interquartile range 93-485] cardiovascular mortality was 2.9% in patients without AR; 13.2% in the mild AR group (P = 0.004 vs. absent AR) and 46.2% in the moderate/severe AR group (P < 0.001 vs. mild or absent AR). On multivariable analysis, post-procedural AR (hazard ratio = 2.65 absent vs. present any grade, 95% confidence interval = 1.11-6.29; P = 0.027) was an independent predictor of mid-term mortality.

CONCLUSIONS

The impact of post-procedural AR on outcomes after trans-catheter aortic valve implantation is proportional with its grade even in case of mild post-procedural AR compared to absent. This study confirms that every effort should be made to reduce the grade of post-procedural AR after trans-catheter aortic valve implantation with current devices.

Influence of aortic regurgitation after TAVI on left ventricular filling pattern

BACKGROUND

Paravalvular aortic regurgitation after transcatheter aortic valve implantation is associated with a hemodynamic deterioration and a poor outcome. We aim to determine the early hemodynamic effect of paravalvular aortic regurgitation in relation with the change in the left ventricle filling pattern and to assess their clinical outcome.

MATERIAL AND METHODS

Eighty-two consecutive patients referred for transcatheter aortic valve implantation were included. Patients were classified according to the change in the left ventricular filling pattern, and significant paravalvular aortic regurgitation (grade ≥ 2) was reported. Follow-up and incidence of death and hospitalization for heart failure were reported.

RESULTS

Sixteen patients (19·5%) presented a worsening of left ventricular filling pattern. The incidence of significant paravalvular aortic regurgitation was higher in the group with a worsening of left ventricular filling pattern (56·3% vs. 19·7%; P = 0·009). In the multivariate analysis, the only variable significantly associated with the worsening of left ventricular filling pattern was the significant paravalvular aortic regurgitation (OR 4·84; 95% CI 1·23 - 19·1; P = 0·024). During the follow-up (642·5 days), there was a higher incidence of the endpoint of death or hospitalization for heart failure in the group with a worsening of left ventricular filling pattern (62·5% vs. 31·8%; P = 0·042) and a lower event-free survival rate (long rank test = 0·013).

CONCLUSIONS

The presence of a significant paravalvular aortic regurgitation is associated with a worsening in parameters of diastolic function. This finding should alert the cardiologist as patients with a worsening of left ventricular filling pattern present a higher incidence of paravalvular aortic regurgitation and a less favourable outcome.

Hemodynamic outcomes of transcatheter aortic valve implantation with the CoreValve system: an early assessment

BACKGROUND AND AIMS

Transcatheter aortic valve implantation (TAVI) is an established method for the treatment of high-risk patients with aortic stenosis (AS). The beneficial effects of TAVI in cardiac hemodynamics have been described in recent studies, but those investigations were mostly performed after an interval of more than 6 months following aortic valve implantation. The aim of this study is to investigate the acute and short-term alterations in hemodynamic conditions using the echocardiography outcomes in patients undergoing TAVI.

METHODS AND RESULTS

A total of 60 patients (26 males, 34 females; age 84·7 ± 5·8) who underwent TAVI with CoreValve system were included in the study. Echocardiography was performed before hospital discharge and at 3 months follow-up. As expected, TAVI was associated with an immediate significant improvement in aortic valve area (AVA) (from 0·64 ± 0·16 cm(2) to 1·67 ± 0·41 cm(2) , P-value<0·001) and mean gradient (from 51·9 ± 15·4 mmHg to 8·8 ± 3·8 mmHg, P-value<0·001). At 3-month follow-up, systolic LV function was augmented (EF: 50 ± 14% to 54 ± 11%, P-value = 0·024). Left ventricle (LV) mass and left atrium (LA) volume were significantly reduced (LV mass index from 126·5 ± 30·5 g m(-2) to 102·4 ± 32·4 g m(-2) ; LA index from 42·9 ± 17·3 ml m(-2) to 33·6 ± 10·6 ml m(-2) ; P-value<0·001 for both). Furthermore, a decrement in systolic pulmonary artery pressure (SPAP) from 47·5 ± 13·5 mmHg to 42·5 ± 11·2 mmHg, P-value = 0·02 was also observed. Despite the high incidence of paravalvular regurgitation (PVR) (80%), most of the patients presented mild or trace PVR and no significant progress of the regurgitation grade was seen after 3 months.

CONCLUSION

This study demonstrates that the beneficial effects of TAVI in cardiac function and hemodynamics occur already after a short period following aortic valve implantation.

Clinical impact of paravalvular leaks on biomarkers and survival after transcatheter aortic valve implantation

BACKGROUND

There is accumulating evidence that up to 20% of the implanted devices after TAVI are associated with a significant degree of paravalvular leaks, which appear to be associated with a negative clinical outcome.

METHODS

A total of 355 patients with severe aortic valvular stenosis (AVS) were treated by TAVI (Corevalve n = 222, Edwards Sapien n = 133). Survival, NT-proBNP and the grade of PVL were quantified up to 12 months after implantation.

RESULTS

Technical success rate was 97.8%. Thirty-day mortality was 9.6%. Post-procedural transvalvular aortic regurgitation was seen only in a minority of cases (5%), whereas PVL were frequently observed (grade: <1+ in 58.2%, ≥1-<2 in 33.9%, and ≥2 in 7.9%). There was a clear relation-ship between PVL and adverse outcome (P < 0.001). After a transient increase, NT-proBNP showed a significant decline. Interestingly, a PVL ≥2+ was associated with a much higher rise in NT-proBNP compared to the other groups (P < 0.01), and a post-procedural increase in NT-proBNP by more than 1640 ng L(-1) within 5 days was associated with a significant increase in rate of death (P < 0.01).

CONCLUSIONS

TAVI is an efficient treatment option for high-risk patients with severe AVS. The incidence of PVL is an inacceptable clinical problem. Serial measurement of NT-proBNP can be used for risk-stratification in patients with a significant PVL. In general, PVL graded ≥2+ is associated with a dramatically increased 6-month mortality. Therefore, any action to reduce paraprosthetical regurgitation is highly recommended.

Prevalence, factors associated with, and prognostic effects of preoperative anemia on short- and long-term mortality in patients undergoing transcatheter aortic valve implantation

BACKGROUND

There is scant information on the prevalence and factors associated with preoperative anemia in patients undergoing transcatheter aortic valve implantation (TAVI) and whether it is associated with mortality. We sought to determine the prevalence and factors associated with preoperative anemia in addition to the prognostic effects of the various levels of preoperative hemoglobin level on mortality in patients undergoing TAVI.

METHODS AND RESULTS

Ten-center observational study encompassing 1696 patients with aortic stenosis who underwent TAVI was conducted. Anemia was defined by the World Health Organization criteria (hemoglobin <12.0 g/dL in women and <13.0 g/dL in men). The prevalence of preoperative anemia was 57%. Patient-related factors associated with preoperative anemia were (descending order of odds ratio [95% confidence interval]) as follows: anemia-related medication (4.90 [3.08-7.80]), history of heart failure (1.77 [1.43-2.20]), male sex (1.69 [1.32-2.16]), mitral regurgitation grade ≥III (1.61 [1.15-2.25]), history of malignancy (1.44 [1.03-2.09]), and peripheral vascular disease (1.33 [1.04-1.70]). The creatinine clearance was inversely associated with preoperative anemia (odds ratio, 0.92 [0.87-0.97]). In multivariable analyses, preoperative anemia was not associated with 30-day mortality (1.72 [0.96-3.12]; P=0.073) but showed the strongest association with 1-year mortality with a hazard ratio (95% confidence interval) of 2.78 (1.60-4.82) in patients with hemoglobin <10 g/dL. Patients with anemia received ≥1 blood transfusion 2× more often, but the indication of transfusion was unrelated to overt bleeding in 60%. Blood transfusion was associated with mortality at 30 days (odds ratio, 1.25 [95% confidence interval, 1.08-3.67]) and during follow-up (hazard ratio, 1.09 [95% confidence interval, 1.03-1.14]).

CONCLUSIONS

Preoperative anemia is prevalent in >50% of patients undergoing TAVI. Various baseline factors were related to anemia, which in turn was associated with 1-year mortality. Patients with anemia received more transfusions but mostly for indications unrelated to overt bleeding, whereas transfusion was independently associated with both early and 1-year mortality. These findings indicate that optimization of baseline factors related to preoperative anemia, in addition to more strict criteria of the use of blood products, may improve outcome after TAVI.

Transcatheter aortic valve replacement in patients with severe aortic stenosis who are at high risk for surgical complications: summary assessment of the California Technology Assessment Forum

BACKGROUND

The California Technology Assessment Forum is dedicated to assessment and public reporting of syntheses of available data on medical technologies. In this assessment, transcatheter aortic valve replacement (TAVR) was evaluated for patients with severe aortic stenosis (AS) who are at high risk for complications.

METHODS AND RESULTS

In this assessment, 5 criteria were used: Regulatory approval, sufficient scientific evidence to allow conclusions on effectiveness, evidence that the technology improves net health outcomes, evidence that the technology is as beneficial as established methods, and availability of the technology outside investigational settings. In this assessment, all 5 criteria were judged to have been met. The primary benefit of TAVR is the ability to treat AS in patients who would otherwise be ineligible for surgical aortic valve replacement. It may also be useful for patients at high surgical risk by potentially reducing periprocedural complications and avoiding the morbidity and recovery from undergoing heart surgery. Potential harms include the need for conversion to an open procedure, perioperative death, myocardial infarction, stroke, bleeding, valve embolization, aortic regurgitation, heart block that requires a permanent pacemaker, renal failure, pulmonary failure, and major vascular complications such as cardiac perforation or arterial dissection. Potential long-term harms include death, stroke, valve failure or clotting, and endocarditis. As highlighted at the February 2012 California Technology Assessment Forum meeting, the dispersion of this technology to new centers across the United States must proceed with careful thought given to training and proctoring multidisciplinary teams to become new centers of excellence.

CONCLUSIONS

TAVR is a potentially lifesaving procedure that may improve quality of life for patients at high risk for surgical AVR. However, attention needs to be paid to appropriate patient selection, their preoperative evaluation, surgical techniques, and postoperative care to preserve and improve on the results attained in the Placement of Aortic Transcatheter Valve trial. Specialty societies are collaborating to ensure that this happens in a rational and comprehensive manner.

Preserved prognostic value of preinterventional troponin T levels despite successful TAVI in patients with severe aortic stenosis

BACKGROUND

Elevated concentrations of troponin T have prognostic impact in patients with various cardiovascular diseases including those with severe aortic stenosis. Transcatheter aortic valve implantation (TAVI) has improved prognosis for patients without a surgical option. Whether this affects the prognostic value of preinterventional troponin T remains unclear.

METHODS

We therefore conducted a prospective study in 198 consecutive patients with subsequent, successful transfemoral TAVI and analyzed cardiac troponin T (cTnT) levels with a new generation, high-sensitive troponin T assay before and after TAVI, as well as their prognostic value after 12 months.

RESULTS

Patients with severe aortic stenosis (AS) showed significant elevation of preinterventional cTnT levels. Postinterventional cTnT levels significantly rose further about sevenfold after transfemoral TAVI and peaked at day three until they steadily declined thereafter. Baseline renal function (P = 0.011), the duration of intraprocedural rapid pacing (P = 0.0012), and baseline cTnT (P = 0.0001) values predicted the magnitude of postinterventional cTnT elevations. Interestingly, Kaplan-Meier curve analysis revealed, that although cTnT levels were not predictive for short-term mortality, preinterventional as well as postinterventional peak cTnT showed prognostic value for 1-year mortality, regardless of successful TAVI.

CONCLUSIONS

Pre- and postinterventional hscTnT levels signal adverse 1-year mortality in patients with severe AS independent of successful aortic valve replacement.

Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature

OBJECTIVES

This study was designed to establish the incidence, impact, and predictors of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR).

BACKGROUND

AR is an important limitation of TAVR with ill-defined predictors and unclear long-term impact on outcomes.

METHODS

Studies published between 2002 and 2012 with regard to TAVR were identified using an electronic search and reviewed using the random-effects model of DerSimonian and Laird. From 3,871 initial citations, 45 studies reporting on 12,926 patients (CoreValve [Medtronic CV Luxembourg S.a.r.l., Tolochenaz, Switzerland] n = 5,261 and Edwards valve [Edwards Lifesciences, Santa Ana, California] n = 7,279) were included in the analysis of incidence and outcomes of post-TAVR AR.

RESULTS

The pooled estimate for moderate or severe AR post-TAVR was 11.7% (95% confidence interval [CI]: 9.6 to 14.1). Moderate or severe AR was more common with use of the CoreValve (16.0% vs. 9.1%, p = 0.005). The presence of moderate or severe AR post-TAVR increased mortality at 30 days (odds ratio: 2.95; 95% CI: 1.73 to 5.02) and 1 year (hazard ratio: 2.27; 95% CI: -1.84 to 2.81). Mild AR was also associated with an increased hazard ratio for mortality, 1.829 (95% CI: 1.005 to 3.329) that was overturned by sensitivity analysis. Twenty-five studies reported on predictors of post-TAVR AR. Implantation depth, valve undersizing, and Agatston calcium score (r = 0.47, p = 0.001) were identified as important predictors.

CONCLUSIONS

Moderate or severe aortic regurgitation is common after TAVR and an adverse prognostic indicator of short- and long-term survival. Incidence of moderate or severe AR is higher with use of the CoreValve. Mild AR may be associated with increased long-term mortality. Therefore, every effort should be made to minimize AR by a comprehensive pre-procedural planning and meticulous procedural execution.

Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high-risk patients with severe aortic stenosis. Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study was to compare AoA dimensions measured by multidetector computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI.

METHODS

Aortic annulus maximum diameter, minimum diameter, and area were assessed using MDCT and compared with TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years).

RESULTS

Aortic annulus maximum, minimum diameter, and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm(2), respectively. Aortic annulus diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm and 353.82 ± 64.57 mm(2) and 22.04 ± 1.94 mm and 384.33 ± 67.30 mm(2), respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65, and 0.69 and 0.61, 0.65, and 0.70, respectively), with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm, and 67.05 ± 55.87 mm(2) and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm, and 36.54 ± 56.43 mm(2), respectively. Grade ≥2 PVR occurred in 46 patients and was related to male gender, higher body mass index, preprocedural aortic regurgitation, and lower mismatch between the nominal area of the implanted prosthesis and AoA area detected by MDCT.

CONCLUSIONS

Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared with echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.

Prosthesis/annulus discongruence assessed by three-dimensional transoesophageal echocardiography: a predictor of significant paravalvular aortic regurgitation after transcatheter aortic valve implantation

AIMS

Paravalvular aortic regurgitation (AR) is common after transcatheter aortic valve implantation (TAVI). This study aimed to assess the prosthesis/aortic annulus discongruence by three-dimensional (3D) transoesophageal (TOE) planimetry of aortic annulus and its impact on the occurrence of significant AR after TAVI.

METHODS AND RESULTS

We included 33 patients who underwent TAVI with a balloon expandable device for severe aortic stenosis. To appraise the prosthesis/annulus discongruence, we defined a 'mismatch index' expressed as: annulus area - prosthesis area. The aortic annulus area was planimetered with 3D TOE, and approximated by circular area formula (π r(2)) using annulus diameter obtained by two-dimensional (2D) TOE. After TAVI, 13 patients (39.3%) developed significant AR (≥2/4). The occurrence of significant AR was associated to the 3D planimetered annulus area (P = 0.04), and the 'mismatch index' obtained through 3D planimetered annulus area (P = 0.03), but not to 'mismatch index' derived of 2D annulus diameter. In multivariate analysis, 'mismatch index' for 3D planimetered annulus area was the only independent predictor of significant AR (odds ratio: 10.614; 95% CI: 1.044-17.21; P = 0.04). The area under the receiver operating characteristic curve for the 'mismatch index' by the 3D planimetered annulus area was 0.76 (95% CI: 0.54-0.92), whereas for 'mismatch index' obtained by the 2D circular area was 0.36 (95% CI: 0.17-0.55). Using the 3D planimetered annulus area as the reference parameter to decide the prosthetic size, the choice would have been different in 21 patients (63%).

CONCLUSION

Three-dimensional TOE planimetry of aortic annulus improves the assessment of prosthesis/annulus discongruence and predicts the appearance of significant AR after TAVI.

Haemodynamic evaluation of aortic regurgitation after transcatheter aortic valve implantation using cardiovascular magnetic resonance

AIMS

Echocardiography may underestimate the degree of paravalvular aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve bioprosthesis due to inherent limitations of ultrasound imaging in the evaluation of implanted cardiac prostheses. We aimed to evaluate the accuracy and feasibility of cardiovascular magnetic resonance (CMR) in quantifying regurgitant volume (RV) and regurgitant fraction (RF) in patients treated with this bioprosthesis for severe calcific aortic stenosis, and to compare the results with echocardiography and aortography.

METHODS AND RESULTS

This study included 16 patients with a mean age of 78.7 years (eight women, eight men) who underwent successful TAVI using Medtronic CoreValve bioprosthesis. AR was evaluated by CMR, echocardiography, and aortography. Angiography was performed immediately after valve implantation. CMR and echocardiography were performed four weeks after valve implantation. There was a highly significant correlation between the CMR-derived and the angiographically-estimated degree of AR (r=0.86, p<0.001). On the other hand, there was only a limited correlation between CMR and echocardiography (r=0.374, p=0.15) as well as angiography and echocardiography (r=0.319, p=0.23) regarding the degree of AR. The weighted kappa for agreement between echocardiography and angiography was 0.14, for agreement between echocardiography and CMR 0.20, and for agreement between angiography and CMR 0.72. Echocardiography underestimated AR by one degree compared to CMR in five patients and 2 degrees in two patients; in six of these, the degree of AR obtained by CMR was similar to angiography.

CONCLUSIONS

In patients undergoing TAVI, comparisons between purely quantitative measurements of AR by CMR and qualitative assessment by angiography showed better correlations than those with echocardiography. This suggests that echocardiography may underestimate the degree of AR and CMR in these circumstances has a great potential in reliably measuring the severity of AR in a quantitative manner.

How should I treat acute valve regurgitation?

BACKGROUND

An 81-year-old male with symptoms of angina and dyspnoea (NYHA 3), a history of coronary bypass surgery, a transaortic peak gradient of 109 mmHg on transthoracic echocardiography and a logistic Euro-SCORE of 21.6 was deemed suboptimal for surgery by a multidisciplinary team and was accepted for TAVI.

INVESTIGATION

Preprocedural diameter of the native aortic root was 24.4 mm on transthoracic echocardiography (TTE), 26.9 mm on contrast angiography and 26.8 mm by 30.2 mm on multislice computed tomography (MSCT).

DIAGNOSIS

heavy calcification of the aortic root and coronary arteries by MSCT.

TREATMENT

Transcatheter aortic calve replacement with an 29 mm CoreValve prosthesis.

WITHDRAWN: Very Early Improvement in Valvuloarterial Impedance Induced by Transcatheter Aortic Valve Implantation (CoreValve) in Symptomatic Aortic Stenosis

The editors have requested that the article be withdrawn because of concern that some of its contents appear quite similar to portions of another publication from the same group of investigators. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Standardized endpoint definitions for transcatheter aortic valve implantation clinical trials: a consensus report from the Valve Academic Research Consortium

OBJECTIVES

To propose standardized consensus definitions for important clinical endpoints in transcatheter aortic valve implantation (TAVI), investigations in an effort to improve the quality of clinical research and to enable meaningful comparisons between clinical trials. To make these consensus definitions accessible to all stakeholders in TAVI clinical research through a peer reviewed publication, on behalf of the public health.

BACKGROUND

Transcatheter aortic valve implantation may provide a worthwhile less invasive treatment in many patients with severe aortic stenosis and since its introduction to the medical community in 2002, there has been an explosive growth in procedures. The integration of TAVI into daily clinical practice should be guided by academic activities, which requires a harmonized and structured process for data collection, interpretation, and reporting during well-conducted clinical trials.

METHODS AND RESULTS

The Valve Academic Research Consortium established an independent collaboration between Academic Research organizations and specialty societies (cardiology and cardiac surgery) in the USA and Europe. Two meetings, in San Francisco, California (September 2009) and in Amsterdam, the Netherlands (December 2009), including key physician experts, and representatives from the US Food and Drug Administration (FDA) and device manufacturers, were focused on creating consistent endpoint definitions and consensus recommendations for implementation in TAVI clinical research programs. Important considerations in developing endpoint definitions included (i) respect for the historical legacy of surgical valve guidelines; (ii) identification of pathophysiological mechanisms associated with clinical events; (iii) emphasis on clinical relevance. Consensus criteria were developed for the following endpoints: mortality, myocardial infarction, stroke, bleeding, acute kidney injury, vascular complications, and prosthetic valve performance. Composite endpoints for TAVI safety and effectiveness were also recommended.

CONCLUSION

Although consensus criteria will invariably include certain arbitrary features, an organized multidisciplinary process to develop specific definitions for TAVI clinical research should provide consistency across studies that can facilitate the evaluation of this new important catheter-based therapy. The broadly based consensus endpoint definitions described in this document may be useful for regulatory and clinical trial purposes.

Usefulness of percutaneous aortic valve implantation to improve quality of life in patients >80 years of age

Older patients with aortic stenosis cannot always be offered conventional surgical aortic valve replacement at an acceptable risk. Transcatheter aortic valve implantation (TAVI) is currently considered an alternative treatment option with lower periprocedural risks. However, its effect on post-TAVI quality of life and clinical improvement has not been systematically and prospectively evaluated in those of advanced age. Thus, the aim of the present study was to assess the clinical improvement in geriatric patients after TAVI, with a special emphasis on quality of life. In the present study, we assessed the quality of life and brain natriuretic peptide in patients aged >80 years, before and 6 months after transfemoral CoreValve implantation. Of 87 prospectively studied patients with severe, symptomatic aortic stenosis at an age of ≥81 years, 80 survived for 6 months and were able to attend the follow-up visit with a quality of life assessment, using the Medical Outcomes Trust Short Form 36-Item Health Survey (average age 86 ± 2.9 years). The average scores of all 8 health components had improved significantly after TAVI. The greatest gain was seen in physical functioning (improvement from 23.4 ± 6.0 to 67.8 ± 13.7; p <0.001). The lowest gain was seen in bodily pain (improved from 37.5 ± 9.4 to 51.3 ± 11.5; p <0.05). Similarly, both the physical and the mental component summary scores improved significantly. This was consistent with significant improvement in brain natriuretic peptide levels (5,770 ± 8,016 to 1,641 ± 3,650 ng/L; p <0.0001). In conclusion, the results of the present study have shown a significant clinical benefit from TAVI in a patient population aged ≥81 years.

Percutaneous transarterial aortic valve implantation: what do we know?

Transcatheter aortic valve implantation (TAVI) is assuming a major role in the routine management of patients with aortic stenosis. Surgical aortic valve replacement is generally accepted to prolong survival, on the basis of historical comparisons and long experience. However, recently percutaneous transarterial TAVI has assumed the position as the only therapy in any aortic stenosis patient group demonstrated to prolong survival in a randomized trial. Arguably, percutaneous TAVI is now the standard of care in symptomatic patients who are not candidates for conventional surgery. On the basis of almost 10 years of experience TAVI also appears to be a reasonable option for some operable, but high-risk patients. Nevertheless considerable work needs to be done before the indications for TAVI are expanded into lower risk groups. We review what is currently known about percutaneous transarterial implantation of the aortic valve.

Early hemodynamic and neurohormonal response after transcatheter aortic valve implantation

BACKGROUND

The conventional surgical aortic bioprostheses used for treatment of aortic stenosis (AS) are inherently stenotic in nature. The more favorable mechanical profile of the Medtronic CoreValve bioprosthesis may translate into a better hemodynamic and neurohormonal response.

PATIENTS AND METHODS

The early hemodynamic and neurohormonal responses of 56 patients who underwent successful transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve bioprosthesis for severe symptomatic AS were compared with those of 36 patients who underwent surgical aortic valve replacement (SAVR) using tissue valves in the same period.

RESULTS

At baseline, patients in the TAVI and SAVR group had comparable indexed aortic valve area (0.33 ± 0.1 vs 0.34 ± 0.1 cm² , respectively; P = .69) and mean transvalvular gradient (51.1 ± 16.5 vs 53.1 ± 14.3 mm Hg, respectively; P = .56). At 30-day follow-up, mean transvalvular gradient was lower in the TAVI group than in the SAVR group (10.3 ± 4 vs 13.1 ± 6.2 mm Hg, respectively; P = .015), and the indexed aortic valve area was larger in the TAVI group (1.0 ± 0.14 vs 0.93 ± 0.13 cm²/m²; P = .017). There was a trend toward a higher incidence of moderate patient-prosthesis mismatch in the surgical group compared with the TAVI group (30.5% vs 17.8%, respectively; P = .11). The overall incidence of prosthetic regurgitation (any degree) was higher in the TAVI group than in the SAVR group (85.7% vs 16.7%, respectively; P < .00001). The left ventricular mass index decreased after TAVI (175.1 ± 61.8 vs 165.6 ± 57.2 g/m²; P = .0003) and remained unchanged after SAVR (165.1 ± 50.6 vs 161 ± 64.8 g/m²; P = .81). Similarly, NT-ProBNP decreased after TAVI (3,479 ± 2,716 vs 2,533 ± 1,849 pg/mL; P = .033) and remained unchanged after SAVR (1,836 ± 2,779 vs 1,689 ± 1,533 pg/mL; P = .78). There was a modest correlation between natriuretic peptides and left ventricular mass index in the whole cohort (r = 0.4, P = .013).

CONCLUSION

In patients with severe AS, TAVI resulted in lower transvalvular gradients and higher valve areas than SAVR. Such hemodynamic performance after TAVI may have contributed to early initiation of a reverse cardiac remodeling process and a decrease in natriuretic peptides.

The next revolution: percutaneous aortic valve replacement

Aortic valve replacement (AVR) is a treatment of choice for patients with symptomatic severe aortic stenosis (AS). However, a significant proportion of these patients do not undergo surgical AVR due to high-risk features. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative for patients with severe AS who are not candidates for open-heart surgery. Since the introduction of TAVI to the medical community in 2002, there has been an explosive growth in procedures. The balloon-expandable Edwards SAPIEN valve and the self-expanding CoreValve ReValving(TM) system contribute the largest patient experience with more than 10,000 patients treated with TAVI to date. Clinical outcomes have stabilized in experienced hands, with 30-day mortality less than 10%. Careful patient selection, growing operator experience, and an integrated multidisciplinary team approach contribute to notable improvement in outcomes. In the first randomized pivotal PARTNER trial, in patients with severe AS not suitable candidates for surgical AVR, TAVI compared with standard therapy, significantly improved survival and cardiac symptoms, but was associated with higher incidence of major strokes and major vascular events. The results of randomized comparison of TAVI with AVR among high-risk patients with AS for whom surgery is a viable option are eagerly awaited to provide further evidence on the applicability of TAVI in these patients.

Left ventricular reverse remodeling in percutaneous and surgical aortic bioprostheses: an echocardiographic study

BACKGROUND

Surgical aortic valve replacement (SAVR) is the definitive proven therapy for patients with severe aortic stenosis who have symptoms or decreased left ventricular (LV) function. The development of transcatheter aortic valve implantation (TAVI) offers a viable and "less invasive" option for the treatment of patients with critical aortic stenosis at high risk with conventional approaches. The main objective of this study was the comparison of LV hemodynamic and structural modifications (reverse remodeling) between percutaneous and surgical approaches in the treatment of severe aortic stenosis.

METHODS

Fifty-eight patients who underwent TAVI with the CoreValve bioprosthetic valve were compared with 58 patients with similar characteristics who underwent SAVR. Doppler echocardiographic data were obtained before the intervention, at discharge, and after 6-month to 12-month follow-up.

RESULTS

Mean transprosthetic gradient at discharge was lower (P<.003) in the TAVI group (10±5 mm Hg) compared with the SAVR group (14±5 mm Hg) and was confirmed at follow-up (10±4 vs 13±4 mm Hg, respectively, P<.001). Paravalvular leaks were more frequent in the TAVI group (trivial to mild, 69%; moderate, 14%) than in the SAVR group (trivial to mild, 30%; moderate, 0%) (P<.0001). The incidence of severe prosthesis-patient mismatch (PPM) was significantly lower (P<.004) in the TAVI group (12%) compared with the SAVR group (36%). At follow-up, LV mass and LV mass indexed to height and to body surface area improved in both groups, with no significant difference. In patients with severe PPM, only the TAVI subgroup showed significant reductions in LV mass. LV ejection fraction improved at follow-up significantly only in TAVI patients compared with baseline values (from 50.2±9.6% to 54.8±7.3%, P<.0001).

CONCLUSIONS

Hemodynamic performance after TAVI was shown to be superior to that after SAVR in terms of transprosthetic gradient, LV ejection fraction, and the prevention of severe PPM, but with a higher incidence of aortic regurgitation. Furthermore, LV reverse remodeling was observed in all patients in the absence of PPM, while the same remodeling occurred only in the TAVI subgroup when severe PPM was present.